Provider Demographics
NPI:1619168614
Name:WHITEAMIRE CLINIC PA INC
Entity Type:Organization
Organization Name:WHITEAMIRE CLINIC PA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSTY
Authorized Official - Middle Name:V
Authorized Official - Last Name:WHITEAMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:567-560-3179
Mailing Address - Street 1:2031 PARK AVE W
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2234
Mailing Address - Country:US
Mailing Address - Phone:567-560-3179
Mailing Address - Fax:
Practice Address - Street 1:2031 PARK AVE W
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-2234
Practice Address - Country:US
Practice Address - Phone:419-529-2055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHT47262111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty